Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Wednesday, May 20, 2009

Hugh Hewitt is a popular radio talk show host, an accomplished academic within the legal profession, a keen political commentator, and an evangelical Christian. He has dedicated this week on his show to physician callers, and asks, in short, what the hell we are doing sitting on our hands while Obama and his cohorts push to completely wreck the best medical system in the world, and thereby, our livelihoods.

I have an answer and it's hopefully not going to come off as an excuse. It is quite simple, I believe that after EMTALA was crammed down our throats in 1986 we all saw the writing on the wall and have simply been trying to muddle through to the inevitable.

This betrays a few weaknesses inherent in most physicians which are as follows. We are not lawyers. The legislature as it stands is populated by a huge proportion of lawyers who are schooled in the ways of legislation and politics, and we are not. We are schooled in what works and what does not. We are incredibly impatient as a rule, especially those of us in the ER. Get it done now or go away. When the monstrosity of EMTALA was enshrined the battle against universal health care was lost. How is the argument even made that we do not have universal care now? And how can one argue that there is a problem with access? I have not been able, ever, to turn a patient away from the ER.

You can be a murderer, an illegal alien, or a John Doe, pick up the phone, call 911, and get all your care (up to and including all manner of surgery) right away at the ER and never pay a dime. Why in God's name would we physicians, as a group, have any other belief than that the battle is lost and was lost some time ago.

Also, even though we have swallowed the bitter pill of universal care (without any legislative disincentive to abuse the system having survived scrutiny) our feeble attempts to bring even a small amount of sensibility to our tort system have been crushed in their infancy by the legal community, most often the American Trial Lawyers Association (and their willing accomplices in the congress). This puts us in the position of being forced to give extraordinary care to everyone who comes through the door regardless of their ability to pay AND bear the full legal consequence of any mistake made in their care up to and including 'pain and suffering' damages from 'malpractice'.

Also, we are not allowed to deduct the cost of this free care we give away, conservative estimates place it at $150k per year per Emergency Physician, and we are taxed in the highest bracket. The thanks are few and fleeting and the idea of mounting a legal challenge to universal care will have to repeal or revoke EMTALA which, I believe, to be impossible. It is impossible because the parade of sob stories before congress will succeed in painting us in the most monstrous light... money-grubbers who care not a whit for their patient's suffering, and the common sense response will be laughed out of Washington, namely that health care is not a right, and that everyone needs to be responsible for their own well-being at least to some degree. Obama has declared it a right for goodness sake.

Hell, Obama got elected by a convincing majority by PROMISING to redistribute wealth and who better to take from than the 'rich doctors'. The myth of the 'rich doctor' is easy to refute to those who appreciate logical argument, but there aren't many remaining who have not sold their souls for the sake of reelection. I know those with warrior spirits would not let this list dissuade them from at least trying to work the system to our benefit but here's the other part of how we arrived at this pons asinorum. Academic medicine.

As a general rule, the hard sciences produce more conservative thinkers than the liberal arts. I have no proof of this other than my own experience with attending law school for over a year and then switching to medicine. Out of my L1 class of 220 there were a small minority of conservatives. But in medical school I think we outnumbered the enemy by about 10%. I had found home.

As one progresses through medical training and residency the choice of whether to remain in the academy or go into private practice tends to split down political lines. There are a lot of advantages to remaining in academia. One generally makes a little less than in private practice BUT one has these convenient indentured servants called 'interns' and residents' who do all the 'scut work'. One is allowed, by this arrangement, to concentrate on writing papers and doing research. The life is attractive and I almost went, recently, back to the dark side simply for my own sanity.

However, it became evident in the interviews that, even at the august institution to which I was applying, the medical side of the academy had sold out to socialism. The attitude in the Emergency Medicine department is that our patients are SO incapable and stupid that we MUST do it all for them. The doctrine of personal responsibility is hard to maintain when you are treating the same person for the same thing for the 30th time that calendar year, each time the patient having called 911 to come in for their nonspecific overwhelmosis, and each time having the patient fail to comply with follow up instructions and fail to quit smoking, drinking, whoring, shooting up, or eating eighteen bags of cheetos a day. All of our national associations are run by the academics.

I understand this, but they are wrong. The end result of universal health care is not hard to discern, it is merely a lower quality care for all, and RATIONING of care. How could it be otherwise? The strong emotional desire to provide the best for all is merely a reappearance of the old Utopian dream, doomed to fail, because there is no one to pull the cart.

And this, Hugh, is where most doctors are. Most of us in private practice have given up trying to reason and argue with those who argue for a living. We are simply going to cut back on our hours, downsize our lives, and try to find other outlets for our talents. I admit that this is passive-aggressive in the extreme but it may be the only arrow in our quiver that will have any effect.

Unfortunately for patients, they will learn of their folly too late and there will be many people dying in 2012 who would not have died in 1990. Doctors, already a vanishing breed, will be on the endangered species list soon. Why would one choose to go to medical school now? Dear Mr. President, before you commit us to Universal Care you should ask if we are going to participate. I am not.

Thank you, Mr. Hewitt, for putting the docs front and center this week, and please check out the other conservative doctor's blogs listed on the links page here. We are simply looking for a leader and a command and a bit of hope and we will fight. Perhaps you can champion our cause? In doing so you will be championing the cause of every citizen of this country.

34 comments:

You're article is great. Touches on all the main points. EMTALA was definitely the victory of Socialized Medicine over Free-Market practices.

As a young person who wanted to be a Physician, I've gone into a holding pattern as far as going into medicine. If I wanted to work for the government I would go into teaching or law. Especially law because of the relative lack of liability.

Heck, now I'm thinking a bit more about Dentistry...it'd save alot of headaches, that's for sure.

dear RW, the dentists are next. i fully believe that the socialized medical experiment will fail and that there will be, and is already, a shortage of physicians. there will have to be accomodations made and, as a big fan of counter-conventional wisdom thought, now might be a great time to go to medical school. here's the bottom line though, if you can do something, ANYTHING else, and look at yourself squarely in the mirror without a regret, then do it.

You're correct. I've even thought of it myself however, my problem is I can't answer that last question yet.

Further, my own gifts in life generally are not designed for medicine. Sure, I can memorize pretty much anything on the fly and on the whole I'm intelligent. Where I really shine is my oratory prowess. I could make "the one" look like a rank amateur in speech giving(he is one in reality, but he gives the illusion of skill because very few people have heard a superb orator). Ergo, people throughout my life have expected me to go into politics.

Sadly, as you've pointed out, physicians typically don't go into politics because their training is so expensive and long. However, no single primary career(as Politics is a secondary one; or it SHOULD be a secondary one, tell that to most members of Congress) has survived my intellectual scrutiny like medicine has(actually, there is Agricultural Scientist, but the good that one could do in that field is blocked by the EU's hatred of genetically modified crops and ivory tower academics isn't really my thing either).

Ergo, a quandary, I could go into medicine but get a very late start(or none at all) in politics(and God knows that we need more decent politicians around). Or I could go into a more strategic primary career(law, teaching, clergy) and use it as a spring board to politics. Of course, there are a number of pros and cons with both positions.

Forgive my rambling, when it comes to this topic, I'm a bit disorganized.

rw, you can do anything you want with a law degree... except practice medicine.

how about aviation? a career, or half a career as a military aviator would be a nice set up for a political career. having seen the world upside down and sideways from the back of a pointy nosed jet i highly recommend it.

The only reason anyone should ever apply to med school is if he/she wants to be a doctor so badly that the idea of doing anything else is inconceivable. If you don't feel that you were called by God to the profession, don't do it.

It is one of the most difficult and demanding professions in the world and the pay is actually quite low, especially in primary care fields.

If you are only "thinking about going to medical school" don't. Don't. If you don't want it more than anything else in the world, it's not worth the sacrifice of the best years of your life and half a million dollars.

My mother said when she started nursing in the 40s she took care of patients, and when she retired in the 90's she took care of paperwork.

My husband and I own a small business, so do both my kids.

While my beautician daughter doesn't have any trouble with people paying for all kinds of beauty treatments, my son the mechanic gets lots of guff about car repair costs. He had to get a credit card machine in order to get paid. That might change too, with the new credit card mess. He was too soft hearted (still is), and he let too many people pick up their cars and "pay him later in the week." We live in a hard hit area of Michigan, and my son said he worked on a tattoo artist's car, who said surprisingly his business wasn't too bad. Go figure.

I theorize that people no longer want to take care of their needs (a running car to get to work, doctor, house payments, food), and are confusing needs with rights. In psychology they talked about Maslow's heirachy of needs; today they need to revise it as an heirachy of rights and wants. Do people who don't feel an obligation to even take care of their basic needs have any pride?

It's not just doctors. Nurses and other medical support staff will be affected. Rationed care will mean caps on pay.

I have always wondered how lawyers could justify eliminating another professional (doctors) from competing in a free market. If the argument is that health care is a right, so is legal representation. The only thing is, I don't get to use a lawyer anytime I want for free (unlike GM workers). I would have to pay for a will, incorporation, real estate deals, etc. I think most lawyers, especially those who are politicians, are elitists. They sit around thinking of how the poor masses should behave to make themselves feel better.

The federal government has taken over private companies already. Should doctors go Galt and slow their work or retire, does anybody think the government will not hesitate to pass laws telling doctors what they will do, how they will work or that they will come out of retirement for the "good of the people"?

I have to agree with my colleague here. I'm an endocrinologist and the hand writing has been on the wall for us for over 20 years. No one, and I mean no one, wants to be an endo. At a time when there is an explosion of diabetics (20 million in US at latest estimate), the number of endos in the US is less than 5000 and 50% of us are more than 60 years old.

Why? No reimbursement for cognition, managed care, and the corporatization of medicine. State medical boards collude with hospitals and insurance companies to drive physicians out of private practice and into being wage slaves of large health conglomerates who are interested at delivering "health" as a fungible commodity. It never has been and never will be.

What I have never been able to figure out about lawyer, is why they can't/aren't sued for malpractice. Every time that some is able to have a new trial because of poor representation, isn't that malpractice on the part of the lawyer?

lawyers can be sued for malpractice though proving it is hard and the damages are somewhat hard to discern. it is a rare event.

would someone out there who actually listened to mr hewitt's show today update me on what was said, if anything, about this post? i am working and have been all week and wrote the post because i couldn't call in.

and dear mr hewitt, if you would like to 'shadow' me in my crazy job to get a first hand view of the mess we are in consider this an open invitation. it's rarely boring and you just might get a book out of it.

I am a board-certified dermatologist who has found a home in the Association of American Physicians and Surgeons. This 60+ year-old organization is dedicated to the private practitioner, and is a principled, conservative, freedom-loving counterweight to the notorious body of physicians committed to a socialist agenda known as the AMA. The Association encourages a return to fee-for-service medicine, with an emphasis on a direct doctor-patient relationship free from the interference of government and insurance companies. After attending their "Thrive-Not Just Survive" seminar, I was convinced to withdraw from participation in Medicare as of 1 October. The loss of revenue will be more than compensated for by the renewed freedom to practice as I wish (especially considering the potential personal and financial risk from Medicare Recovery Audit Contractors who will begin their invasion of private practices next year). A return to free market principles is the only solution that will save us, our profession, and our patients from enslavement by and utter dependence on the government.

Hey Doc, congratulations on making two good decisions... 1. dermatology 2. dropping medicare. i am going to join AAPS, didn't know anyone like that existed. my college, ACEP, is so sold down the river that i can barely stand to read their monthly newsletter. in the seattle national conference three years ago they had as their keynote speaker... drum roll please, catherine crier (sp?) the newsbabe. really, WTF? she lectured us on our responsibility. i checked and she wasn't a doctor. ACEP advocates for patients, so does the AMA. stupid. i do believe that our organizations should advocate for us as this is the essence of a free market system. the deal was done long ago though and i was not even out of med school when my fate was determined though all the docs i knew in the eighties tried to steer me away. had to do it, it is my calling.

interestingly, my attempts to open a fee for service practice have failed because the consultants i hired thought i had just landed from mars. they showed me charts and graphs about why i was destined to fail and not being your typical rich doctor i could not afford to risk it. i do believe that a fee for service practice would work as my bill for, say, a simple laceration repair would be one tenth of the bill from the ER. i haven't given up the fight yet. perhaps we CAN fight this. thanks for your comment.

I am a board certified OB/GYN. I was run of OB long ago due to such high malpractice rates, although never sued, that I'd have to work more than 60 hrs week just to make enough to cover overhead and still pay bills and child care fees. Now I do part-time gyn, and will have to give up surgery for the same reasons. My patients like me, I love the art of medicine and the science of thought. Unfortunately our society believes that everyone else but the individual is responsible for their personal health and problems.

I must counter an above comment that "everyone has universal care". Yes, the ED gets dumped on, because most folks can't afford insurance for preventive care, then get stuck with emergencies. My husband runs an indigent care clinic, at which I volunteer. Most of the women are "working poor" and are struggling to make ends meet. Safety net outpatient medicine certainly decreases overall cost, and the huge burden on our ED staff. Notice, given the above job descriptions, that our two physician family is making less than 50% the average of a one-lawyer D.C. family...

notice, i did not say that 'everyone has universal care' but that if one simply makes it to the ER they DO, in fact, have universl care for acute or emergeny illnesses. also, access is likewise universal because of the ER. i am not saying this is good. it is, in fact, terrible, because, on my end, it is easy to get sucked in to the parade of 'not sick' patients when the 'really sick' one gets put on the 'fast track' side because they are 24 and a 'typical seeker'. about 15% of my patients need to be in an ER, the rest need a clinic appointment or a phone call with their doctor.

in fact, the lack of primary care access is one of the reasons that ERs are closing and hospitals are pulling some tricky maneuvers to stop the money hemorrhage from their ERs.

the way they are doing this is by downstaffing the ERs to skirt EMTALA and letting the long wait-times sift out those without the gift of patience. unfortunately, these 'left without being seen' patients are often truly sick and the only thing that the hospital has done by the downstaffing is to cover its ass. and they are right to do it because a functioning and solvent hospital is better than nothing. but why is it such a mystery that this is happening? it's very simple. try running a grocery store being forced to give your produce away to everyone who says they are hungry. at this point you diverge into the free-market capitalism side (sign me up) or the communist side because if you think the grocer is so obligated then you are a communist.

in fact, the deception being practiced by hospitals is so bad that i recently worked at one that built a shiny NEW facility with three times the beds and an ER that had twice the beds. there was fanfare, there were media days, and there was a ribbon-cutting ceremony. the town thought their problems with the hospital were over. they did not hire any more nurses however, and fifteen of these new ER beds are 'dark' all the time. in fact, they are seeing fewer pateints in the newe ER than in the old, smaller facility, and trying to make ends meet on inpatient procedures which are referred by physicians who take, gasp, insured patients.

notice the layer upon layer of lies built up by the THEFT created by EMTALA. go to the administration and ask for more nurses and you are told that 'your numbers don't justify more nurses'. lying sacks of shit, they are very close to fraud with this move but since no one has written a law they will get away with it BUT WE DON'T WANT ANOTHER LAW.

the last thing we need is another unfunded mandate from on high about how to do our jobs. we need to be released from the handcuffs.

dear anonymous, you have probably landed in a place where you are desperately needed, incredibly underpaid, yet taking care of people with some shred of the notion of responsibility left. your patients have gone to the trouble of finding out about your clinic and have come to you. mine just pick up the phone and call 911 though we do have all manner of indigent clinic and health department beds available. problem is, in the indigent care and health department clinics you can't get everyhing you need, right now, for free.

with market forces removed from medicine, and a valuable service (often involving life and death) declared a 'right', the floodgates opened and medicine, as a sustainable, excellent profession was doomed. why does anyone imagine that the very people that wrecked this system will build a better one or figure out how to make a square circle?

Ever notice how physicians look to everyone but themselves to solve their problems? Why is the world's wealthiest profession (earnings on average 50% higher than the next wealthiest profession) so politically inept? It's not for lack of funds.

Have you been riding the govt. gravy train for so long, that you're unable to get off?

"The legislature as it stands is populated by a huge proportion of lawyers who are schooled in the ways of legislation and politics, and we are not."

By the way, this is a nonsensical excuse. First, in state legislatures there are fewer and fewer practicing lawyers. In the national legislature, while there are lots of people with law degrees, and many criminal prosecutors, you have few people who ever practiced civil law, and probably less than 1% who ever did plaintiff's civil trial work. I can think of more practicing physicians (Paul, Coburn) in Congress than plaintiff's lawyers.

But the real reason that's a weak argument is because there are tons of groups who aren't lawyers who are excellent at lobbying for their cause. And they do not have near the money you guys do.

If you're inept at pushing legislation, it's either because 1) you're too lazy, or 2) more of you are satisfied with the status quo of govt. run healthcare than you will admit.

Well, I'm late to the game after a long camping trip and suppose I started this with my comment about Hewitt.

I loved what Becky said. I loved what Doc Roberts said. 911, to me, sounds like somebody that has his head and heart in the right place, but no toolbox.

I was once a kid with a mind and a serious hankering for medicine. As one of the top kids in my undergraduate school, I was "asked" (read, you shall go) to take a class named "Ethical Issues In Medicine", taught by a useless whiner, visiitng professor from the University of Tennessee, named Jerry Vorwerk (sp?). What a useless piece of human debris she was and probably still is. That was around 1982, long before EMTLA. That was the first generation of 1960s professors infecting the system. I decided, after purposely faiing her class, that I would never work in a place where people like that were second guessing me.

Those of you that met the Jerry Vorwerks and put up with it made your beds. I went into straight biology and battle the "academics" and win, for the rights of citizens that should not be run over by people that call themselves scientists.

Currently, I have gone completely Galt, and have dropped my income to below $30K, working part time and finding odd jobs, just so I no longer have to pay most of my earnings to people that will sit on their rears.

This is not about medicene, solely. All facets of the American life have been hollowed out by the tort lawyers and ivory towers. Many years ago, I discovered that I could not even buy monofilament fishing line, or nets, for my projects, that were made in this country. We, the cleanest, safest country, can't manufacture anything, anymore. Instead, for my ecological research, I have to buy my supplies from China, where they dump their waste in the ditch out back.

In the medical business, it is important for you to know that their are people like me out there. I pay cash or use a credit card for any medical expenses. No insurance, by choice. No debts. Wake up, out of your reverie, and realize that there are customers that want a choice, regardless of what the numbskulls in D.C. do, and address that market.

Forget about the ridiculous and bureaucratic medical centers. Set up your own businesses and the customers will come.

In the old Soviet system, everybody got to see a doctor, but they were not doctors in any sense that you or I would recognize (I know; I minored in Russian and I was there, before the Iron Curtain fell). Their word for doctor is (more or less) "vrach". These are not really doctors, but more like medics or PAs, or NAs. Nothing against medics, PAs, or NAs, but when they level the whole nomenclature, the customer/patient is not foremost in their thoughts.

American medicine is about to become an institution of nothing but bureaucrats and vraches. See the free-market need; get your lives back and market to customers that pay their bills and eschew lawyers.

It sounds simple and I know it is not, but get out there and do it.

We're waiting. I don't participate in Medicare or Medicaid (except for paying for it) and won't touch an insurance company until you can get clean, high deductable, catastrophic-only coverage. I can't be alone and I expect that we will soon see many others like me.

I know a guy from college days that I have heard has made this his specialty. I haven't talked to him in 25 years, but I'll look him up and see what he may have to say that may be of use.

i would like to answer in more complete form but i don't know what your 'toolbox' comment means.

my wife and i are preparing to 'go galt' in about 8 months.

i attemtpted to open a fee for service clinic last fall but ran into many problems, one of which was called 'fear'... wouldn't be a problem if i did not have the family to support. consultants waved papers in front of me citing many failures of just my type of clinic.

if fee for service is ALLOWED after the communist in chief finishes then that's where i'll be. if not, i will simply work for the government and work less, make about the same, and quit caring. as much as that pains me it might be a lot more healthy for my marriage and family... already got the 'been there done that' bug about the ER so if you told me i could sell hot dogs for a living tomorrow i would do it.

First, I'd appreciate your source for the data naming physicians as the "world's wealthiest profession". I am aware of US Labor Department surveys (which exclude a great number of professions), and were not intended to be used for conclusions. They are only a raw data publications (since their scope is limited). Anyway, the US Labor Department usually doesn't make pronouncements about the "world", so I'm sure you have a reliable source for this "fact" and I am anxious to read it.

As for the numbers in the Labor Department stats...do you wonder why you don't see professional football players, baseball players, hedge fund managers, Corporate CEO's, trial lawyers, Hollywood producers/actors, etc on the lists? Maybe you should check into a Community College near you and see if they have a stats course.

Second, it's GREAT to know that: "in state legislatures there are fewer and fewer practicing lawyers"! Outstanding news (unless they are practicing instead). Could you please reference your source for this data? I'd like to know if this is true for all 50 states, or just for certain ones.

Third, how do you get the data for who is a "practicing" physician or lawyer within a legislative body? Further, where do you get the data for the type of law currently or previously practiced by the individual legislatures with law degrees? I'd like to refer to the info you so confidently cite to verify it for myself.

Fourth, the point that 911 made was that Congress is polluted with lawyers (that means people with law degrees, or people who went to law school) who are schooled in the ways of legislation. Though it has nothing to do with your points about types of law and active practice etc, I'd still like to verify your stats.

Fifth, In the 109th Congress, there were 14 members with medical degrees (including the one that you can think of to "make your point") and 228 with law degrees. A year later, in the 110th Congress, there were 13 members with medical degrees and 236 with law degrees. Just to put some actual numbers to the issue, and not generalities.

Finally, I have to agree with you on one thing. Doctors do a terrible job of lobbying for their own cause.

As to toolbox, I had in mind Doc Roberts' comment that may be a better professional organization.

Toolboxes are my freedom and independent of my daily hassles. A visiting friend had problems with her motor home, this weekend. I was able to draw upon drill bits and taps to make bad things better, a very different thing than being frustrated about something that is broken.

As a biologist, I have no professional organizations to which I can belong. Years ago, I had to cancel my membership in the best of them, the Nature Conservancy, because the NC lost its way.

At least within the medical profession, you still have many kindred spirits and the possibility (per Doc Roberts) of an organizational focus. Within biology, there is no such thing and there might not be more than a couple of dozen conservative conservationists left. Folks like me are a dying breed. We're called biostitutes and are consideed sellouts, within our profession. The great irony in that is that my critics scramble for your money, to be taken away from you, to support their work.

I often work for free, representing private landowners and small businesses that could never afford my standard rates, and I only win if I'm right. No private landowner or small busines can stand up against university or government biologists with, essentially, unlimited resources paid for by you.

I don't lose. I represent principled, but polite, accurate science.

In the second place, 911 is correct; you can't go Galt as I have. I have no debts; I have no children; I have no wife. The people that would put me out of business have nothing to grab hold of and I keep it that way. I keep a part time corporate job to help pay the bills, but that's a joke. They dropped nearly 60 megs of files on me yesterday for a bid package, at 10 am, and it had to be done and out by noon. And it was backwards. That's right I had to read and evaluate that much bureaucratic crap in, say, 30 minutes, then prepare and submit a response in an hour and a half. And it was backwards and none of the vaunted government bureaucrats had noticed, no other bidder had noticed. Our bid is correct.

I have driven many bureaucrats into the woods and had one exclaim, "What have you done to the cypress trees!" I told her, "Welcome to Florida in the winter, the state in which you live, where we have deciduos conifers and evergreen oaks." Probably 90% of government biologists need serious help; most Fish and Game type agencies, or Forestry agencies being exceptions. The ones in the EPA and those in similar state agencies are often completely clueless about field biology.

Sound familiar?

You need a toolbox. There is no toolbox in biology, as most money flows down through the state or federal governments, so it's all about going along to get along. Approaching 90% of all money flowing towards biology, in the field, derives from federal, state, or way-left NGO sources. As a result, most "field biologists" are agenda-driven.

Medicine can become this way, as well, if you allow it.

However, there is one, significant, difference. In medicine, you can help a patient, just as I can in biology with a private citizen. The difference is, I will be ridiculed and defamed, with never a clear answer about what I may have accomplshed, whereas you will, possibly, have a properly treated patient.

Just because I may do the proper thing, for both biology and an individual on a given day, doesn't mean they won't change the rules tomorrow, then drag that person back into court, retroactively. You, on the other hand, may have a live patient to point to, which is rather empirical.

911If you're going gov, you're not going Galt. You are signing over Rearden Metal for production for the state (Dagny will finally come clean about the affair). When you do finally go to the secluded camp in Colo., call me and I will come. CAT

'cat, you are correct of course. but my plans are to write about the beast from within its belly, so i hope this counts for something. the secluded camp will either be in rural kentucky or the mountains of montana, wyoming, or alaska. you are your clan are welcome. bring guns, food, and no lawyers.

As an aging patient, I find this thread distressing. I have paid for insurance all my life, although I think insurance should be for unexpected expenses, not a form of pre-paid healthcare with an expensive middleman.

I also want competent, caring doctors to be there. If I have to, I'll pay the concierge fee for a primary care doctor to use real cognitive skills (if I can find one who thinks rather than acts like a highly trained maze running rat).

The threat of losing my insurance (pre-existing conditions) is very real - if I had to pay fee-for-service out of my own pocket for any of a bunch of treatments, my carefully build retirement nest-egg would go down a rathole, and I too would be on the public dole. Note that many Americans feel this threat and want the government to solve it (because in the current situation, there is no possible way for private industry to do so due to adverse selection effects).

(2) My understanding is that American Med Schools have fewer authorized graduation slots for MD's than in 1970. That represents an artificial restriction of supply that cannot be good for the system. Regardless of what those who made it through the selection process may believe, there are a whole lot of smart, educated, empathetic people who might have chosen medical school if it were not for the irrational selection model (take a look at the MCAT physics section, for example - and physics is my subject).

3) Will the shortage of US physicians be filled by foreign (as opposed to just foreign trained) physicians? Are there enough incentives?

4) How much of the problem is government and how much of it is the whole cost-containment model that the private insurance companies use?

5) If you get a malpractice lawyer in your ED, triage him/her/it to the morgue.

unfortunately it is folks like you, who have done everything right all their lives in terms of planning and saving and obtaining insurance who are going to get screwed with Obamacare.

in terms of competent and caring doctors we still have them but we are completely at the mercy of a huge bureaucracy that has no head and can not be killed. in fact, i did a series last summer on the top ten reasons that i am leaving emergency medicine and if you care to look at the posts most of them have to do with a complete failure on my part to effect any meaningful change within my little ER in bumfooodle USA.

the rise of the midlevel practitioner (nurse practitioners and PAs) is an inevitable and necessary consequence of the mandate of EMTALA to treat all comers regardless. they cost less and have less training but we would not survive without them.

foreign medical graduates are going to be a huge presence and are already. some are fantastic, some are not, but, as a rule, there is no substitute for American (or Australian) medical training... maybe Canada and Britain as well.

caring gets hard in the ER, tonight is a perfect example. i had two patients near death that took all my time, one a neonate, one a geriatrics patient. i spent about three hours of my ten hour shift with them, one will probably die, and the other ten patients were mostly understanding, but the one from jail who threatened to kill me two nights ago when she was here has hit the nurse call button about fifteen times now, she will not pay a dime for her care, you will, and there's not a damned thing i can do about it. in fact, if she complains about the care she received tonight, which was excellent, i will be in trouble.

i love medicine, but it's killing me, and it's killing a lot of my colleagues who went into medicine yes, to make a nice living, but more than that, to do something worthwhile and important. it's quite tragic.

the other tragedy is that i can do all that i do in the ER quite easily within the confines of a clinic and charge one tenth of what the ER charges but my attempt to start a clinic like this failed because any successful clinic like that will give the lie to the Obama-ites and will not be tolerated. it would be 'discriminatory' and 'uncaring' even though the patient would be out of pocket less then they would visiting the ER (if they have insurance)... the non payors would not come in and that would be fine with me because the non payors, are generally, like the gentleman i cared for earlier tonight who is addicted to narcotic pills and is 'broke' but managed to buy himself a sooped-up four wheeler a a week ago in 'an attempt to get of the narcotics'. he lives in govt. subsidised housing and claimed, with his $2000 a month habit, to be unable to afford his $8 prescriptions. people lie.

i don't agree that the private sector can not fix this, but there are so many shackles on us that there is almost no supply-demand force allowed to happen right now. right now, the government has made it, by law, unlimited supply regardless of demand. idiocy or crazy like a fox.

could not agree more with the antiquated med school admissions process but it's even more evil than you think. for the last twenty or thirty years the one thing you needed to get into medical school was to be female or a minority. the idiocy here is that women rarely practice full time after their training and that is another artificial limitation on doctor supply. never mind the fact that all those admitted based on diversity will forever face that uncomfortable feeling that they might not have earned it.

there are not enough incentives but the only one that would work is to let doctors be in charge again of their particular area of expertise. in four years at my previsou hospital i could not even succeed in getting the lab to allow for bedside testing (point of care testing) because the lab director didn't want his budget to shrink.

i can not answer as to how much is govt. induced versus cost containment model but do believe that he cost containment model was a result of government tinkering.

finally, i have no personal beef with malpractice lawyers, doctors do some stupid things and the threat of lawsuits does keep us on our toes BUT the current 'lottery' climate is ridiculous and the few ambulance chasers give the rest a bad name. i have testified twice for the plaintiff in cases which were horribly managed and many more times for the defense, but if bart durham shows up in my ER i may just have to ask another doc to see him.